Rod Prep Technician Application

Employment Application

In accordance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, region, sex, national origin, age, marital status, veteran status, non-job related disability, or any other protected group status.
TO BE READ AND SIGNED BY APPLICANT

I authorize you to make such investigations and inquiries of my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.) I hereby release employers, schools, health care providers and other persons from all liability in responding to inquiries and releasing information in connection with my application.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I also understand that I am required to abide by all rules and regulations of the Company.

I understand that information I provide regarding current and/or previous employer may be used, and those employer(s) will be contacted for the purpose of investigating my safety performance history as required by 49 CFR 391.23(d) and (e).

I understand I have the right to:
• Review information provided by previous employer(s)
• Have errors in the information corrected by previous employer(s) and for those previous employer(s) to re-send the corrected information to the prospective employer
• Have a rebuttal statement attached to the alleged erroneous information that I, and the previous employer(s) cannot agree on the accuracy of the information.
Name

First NameLast Name
Last 4 Of Social #
Signature
Date

MonthDayYear
Date

EMPLOYMENT HISTORY

Please list at least 3 to 5 years of employment history especially if it's relative to the current position you're applying for. Please list your most recent job first.
CURRENT OR MOST RECENT EMPLOYMENT
Phone # of Contact/Supervisor
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Position Held
Dates Employed:
Reason For Leaving
Salary
Explain Any Gaps In Employment
If Currently Employed do you give permission to call for reference (A 'no' answer does not disqualify you from the application process)

NEXT EMPLOYER
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Position Held
Dates Employed:
Reason For Leaving
Salary
Explain Any Gaps In Employment
NEXT EMPLOYER
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Position Held
Dates Employed:
Reason For Leaving
Salary
Explain Any Gaps In Employment

NEXT EMPLOYER
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Position Held
Dates Employed:
Reason For Leaving
Salary
Explain Any Gaps In Employment
NEXT EMPLOYER
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Position Held
Dates Employed:
Reason For Leaving
Salary
Explain Any Gaps In Employment
If needed please upload more employment history for the 3-5 year requirement.

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ACCIDENT RECORD FOR THE PAST 3 YEARS-list most recent first

Rows	Date:	Nature of Accident	Number of Fatalities	Number of Injuries	Chemical Spills (Y/N)
-
-
-
-

Check this box if none

TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS

Rows	Date	Violation	State of Violation	Penalty
-
-
-

Check this box if none
Have you ever been denied a license, permit, or privilege to operate a motor vehicle? If yes please explain:
Has any license, permit or privilege ever been suspended or revoked? If yes please explain:

DRIVERS LICENSE OR PERMITS HELD IN THE PAST 3 YEARS

Rows	STATE	LICENSE NUMBER	CLASS	ENDORSEMENT(S)	EXPIRATION DATE
-
-
-

How many years of CDL experience do you have?
How many years of Truck/Trailer combo experience do you have?

EDUCATION

Rows	NAME AND LOCATION	COURS OF STUDY	YEARS COMPLETED	GRADUATED (YES/NO)	ANY ADDITIONAL DETAILS
HIGH SCHOOL
COLLEGE
OTHER

PROFESSIONAL REFERENCES-please list at least 3

Rows	FULL NAME	VALID PHONE NUMBER	YEARS KNOWN
-
-
-

PERSONAL REFERENCES-please list at least 3

Rows	FULL NAME	VALID PHONE NUMBER	YEARS KNOWN
-
-
-

For Faster processing, please upload a copy of your drivers license

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To be read and Signed by applicant

This certifies that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge.
Should be Empty:

Employment Application

APPLICANT INFORMATION